A nurse is caring for a 4-month-old infant who is immediately postoperative following cleft palate repair. Which of the following actions should the nurse take?

Give the infant liquids using a small spoon with a long handle.

Apply elbow restraints to the infant.

Gently check the infant's suture line using a padded tongue depressor.

Place the infant in a supine position.

Answer and Explanation

The Correct Answer is B

A. Give the infant liquids using a small spoon with a long handle.

Give the infant liquids using a small spoon with a long handle.While feeding is essential, the method described is not specific to postoperative care after cleft palate repair.Feedings are resumed by bottle, breast/chest, or cup per surgeon preference; some surgeons prescribe the use of an Asepto syringe for feeding or a soft cup such as a soft-tipped sippy cup.

B. Apply elbow restraints to the infant.

Apply elbow restraints to the infant is correct.Elbow restraints would be used to prevent the infant from injuring or traumatizing the surgical site.

C. Gently check the infant's suture line using a padded tongue depressor.

It's important to assess the surgical site for signs of infection or bleeding, but using a padded tongue depressor may not be the most appropriate method. The nurse should follow the surgeon's orders regarding wound care and assessment techniques, which may include visual inspection without manipulation.

D. Place the infant in a supine position.

Placing the infant in a supine position is generally recommended after cleft palate repair surgery to minimize strain on the surgical site and promote healing. However, it's essential to ensure proper positioning to prevent aspiration and maintain airway patency.

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Correct Answer is A

Explanation

A. Report of diplopia

Diplopia, or double vision, can be a symptom of increased intracranial pressure (ICP) due to its effects on cranial nerve function. Therefore, it is a manifestation that the nurse should recognize as indicating the presence of increased ICP.

B. Hyperactivity

Hyperactivity is not typically associated with increased ICP. Instead, manifestations of increased ICP often include altered level of consciousness, lethargy, or even coma.

C. Nuchal rigidity

Nuchal rigidity, or stiffness in the neck, is not a direct manifestation of increased ICP. It is more commonly associated with meningitis or other conditions affecting the meninges.

D. Report of sore throat

A sore throat is not typically associated with increased ICP unless it is related to complications such as pharyngeal injury or infection.

A. Have the child perform passive range-of-motion exercises. B. Administer aspirin as needed for pain. C. Place ice packs on the affected joints. D. Position the lower extremities below the level of the heart.

Correct Answer is C

Explanation

A. Have the child perform passive range-of-motion exercises: This is not recommended during acute hemarthrosis in hemophilia because it can further exacerbate bleeding and increase joint damage. Passive range-of-motion exercises should be avoided until bleeding has been adequately controlled.

B. Administer aspirin as needed for pain: Aspirin is not recommended for pain management in hemophilia due to its antiplatelet effects, which can further prolong bleeding. Instead, acetaminophen (Tylenol) or other nonsteroidal anti-inflammatory drugs (NSAIDs) that do not affect clotting mechanisms may be used for pain relief.

C. Place ice packs on the affected joints: This is a recommended intervention. Ice packs can help reduce inflammation and swelling in the affected joints, providing pain relief and potentially slowing down bleeding. However, it's important to ensure that the ice pack is wrapped in a cloth or towel to prevent direct contact with the skin, which could cause tissue damage.

D. Position the lower extremities below the level of the heart: This is not recommended. Elevating the affected extremity above the level of the heart can help reduce swelling and minimize bleeding. Placing the lower extremities below the level of the heart could potentially increase bleeding.

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A nurse is caring for a 4-month-old infant who is immediately postoperative following cleft palate repair. Which of the following actions should the nurse take?

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